Cesarean Section Scar Defect Research Articles

Outcomes of Vaginal Repair and Vaginal Repair Combined With GnRHa Administration in the Treatment of Cesarean Section Scar Defects: A Randomized Clinical Trial

Study ObjectiveTo prospectively investigate whether the application of vaginal repair (VR) of cesarean section scar defect (CSD) combined with a gonadotropin-releasing hormone agonist (GnRHa) achieve better clinical outcomes than VR alone. DesignA randomized clinical trial. SettingUniversity hospital. PatientsA total of 124 women with CSD were undergoing expectant management from December 2016 to September 2021. 61 were randomised to VR+ GnRHa and 63 to VR alone. InterventionVaginal repair combined with GnRHa and vaginal repair alone. Measures and Main ResultsThe primary outcome was the duration of menstruation and thickness of the remaining muscular layer (TRM) at 6 months after surgery. Secondary outcomes included the length, width and depth of the CSD; operation time; estimated blood loss; hospitalization time; and operative complications. Women were treated with either VR (n = 63) or VR + GnRHa (n = 61). Menstruation and TRM in patients pre. vs. post comparisons either with VR or VR + GnRHa are significant improved (P < .05). Significant differences in menstruation duration and TRM occurred in patients treated with VR + GnRHa compared with those treated with VR (P < .05). Moreover, the rate of CSD after surgery in the VR group was significantly higher than that in the VR + GnRHa group (P = .033), and CSD patients in the VR + GnRHa group achieved better therapeutic effects than those in the VR group (P = .017). Patients who received VR + GnRHa had a shorter menstruation duration and a greater increment of TRM postoperatively than did patients treated with VR alone (P = .021; P = .002, respectively). ConclusionVR + GnRHa therapy has a greater potential to improve scar healing and reduce the number of menstruation days than VR alone for symptomatic women with CSD. PrécisVaginal Repair Combined with GnRHa Creates Better Therapeutic Effects of CSD. Trial registrationDate of registration: October 13, 2016, Date of initial participant enrollment: December 20, 2016, Clinical trial identification number: NCT02932761, URL of the registration site: ClinicalTrials.gov, Figshare DOI: 10.6084/m9.figshare.24117114 Link to the clinical trial registrationhttps://clinicaltrials.gov/study/NCT02932761

Chronic Endometritis in Cases with Cesarean Section Scar Defect

Chronic Endometritis in Cases with Cesarean Section Scar Defect

The dislocation of the intrauterine device (IUD) into the uterine cesarean section scar defect has a high risk of recurrence

The dislocation of the intrauterine device (IUD) into the uterine cesarean section scar defect has a high risk of recurrence

P-327 Intrauterine fluid in patients with cesarean section defects in association with ivf outcomes

Abstract Study question This study evaluate the effect of cesarean section scar defects associated with intrauterine fluid during endometrial preparation on pregnancy outcomes. Summary answer Patients with Cesarean section scar defect and intrauterine fluid during endometrial preparation had a substantially lower pregnancy outcome compared to those without uterine fluid. What is known already The Cesarean section rate in developed countries has increased continuously, leaving many short-term and long-term consequences. Intrauterine fluid, which reported incidence may reach 40% in patients who have had a previous caesarean section, may play an important role in reducing endometrial receptivity and further impair pregnancy outcomes. Study design, size, duration This is a retrospective cohort study performed on patients who had undergone frozen embryo transfer at an Assisted Reproductive Technology Center from January 2019 to December 2019. Participants/materials, setting, methods 2,350 patients without intrauterine fluid and 74 patients with Cesarean section scar defect who had intrauterine fluid during endometrial preparation but none at progesterone supplementation were analyzed. Multiple logistic regression was performed for the probability of the pregnancy outcome of embryo transfer and measured the association with the status of intrauterine fluid, age, endometrial thickness, number of previous transfer, number of embryos, type of infertility, and difficult embryo transfer at the alpha level of 0.05%. Main results and the role of chance The outcomes among 2,424 patients undergoing cryopreserved embryo transfer were 59.45% for pregnancy rate, 8.7% for biochemical pregnancy rate, 50.33% for clinical pregnancy rate, and 43.15% for ongoing pregnancy rate. The analysis of multiple logistic regression indicated that the presence of intrauterine fluid during endometrial preparation did not affect the pregnancy rate. However, in patients with intrauterine fluid, there was an increased rate of biochemical pregnancy (OR 2.46, 95%CI 1.35-4.50) and a reduced rate of ongoing pregnancy (OR 0.54, 95%CI 0.32-0.89). Limitations, reasons for caution The major limitations of the present study are the retrospective design and small number of patients with uterine fluid. Additionally, the composition of the uterine fluid (eg, blood, mucus, purulent, or transparent) cannot be classified by an ultrasound exam. Wider implications of the findings Intrauterine fluid may be an innovative and controllable factor that should be considered in patients who have a history of caesarean section in order to improve pregnancy outcomes. Trial registration number Not Applicable

Khuyết sẹo mổ lấy thai: Tổng quan về triệu chứng, chẩn đoán, thực trạng, một số yếu tố liên quan và điều trị

Abstract: The study aimed to review studies on cesarean scar defect incidence and its associated factors, diagnostic criteria, and treatments. The study reviewed 44 articles from PubMed in August 2022. Results showed that transvaginal ultrasound and contrast-enhanced hysterosalpingogram were the two most 17 common methods, often used together for diagnosing. The rate of cesarean scar defects ranged from 19% to 84%, depending on the diagnostic method. Common symptoms were irregular menstrual cycles, abnormal bleeding after menstruation, lower abdominal or lower abdominal pain, menstrual cramps, and infertility. Factors associated with cesarean section scar defects included individual factors (parity, number of cesarean deliveries, history of diabetes, uterus recline, maternal body mass index) and medical service factors (stitching technique at cesarean section, prolonged labor period). Treatment included both medical and surgical, but should only be done when there were symptoms affecting the mother's health. Given the high rate of C-section in Vietnam and very few studies on cesarean scar defects, it is necessary to conduct research on this topic in the future. Keywords: cesarean section scar defect, cesarean section, infertility, lower abdominal pain, abnormal bleeding between two menstrual cycles.

Surgical repair of a cesarean scar defect using a vaginal approach

To discuss the signs and symptoms of a cesarean section (C-section) scar defect, and to describe the techniques to repair the defect using a vaginal approach. A video review of a 32-year-old woman with abnormal bleeding and a C-section scar defect managed surgically by vaginal repair. The patient provided consent for video recording and publication. This surgical report, with no identifying patient data, was exempt from the institutional review board approval. Tertiary care facility. A 32-year-old gravida 2, para 2 woman was seen with prolonged menses, and an 11 × 9 × 5-mm C-section scar defect was seen on transvaginal ultrasound. The patient opted for the repair of the C-section scar defect using a vaginal approach. Postoperative course. The patient had resolution of her prolonged menses, and transvaginal ultrasound showed improvement of her C-section scar defect. The vaginal approach is an efficacious way to repair a C-section scar defect, particularly when the defect occurs low at the level of the cervix.

Isthmocele—a New Obstetric Surgery Sequela for Laparoscopic Surgeons

Cesarean section is a common obstetric surgery worldwide. It leads to hitherto unrecognized but not too uncommon sequela known as isthmocele—which is a cesarean section scar defect in the uterus which goes mostly unrecognized and is not cared for. It is certainly not asymptomatic nor totally benign. Such patients suffer from lower abdominal pain, abnormal menstrual bleeding, and secondary infertility including in vitro fertilization (IVF) failure, and they were not responding to a medical treatment. This defect was recognized in a case series of 17 patients and was successfully treated by a laparoscopy repair. Saline-filled hysteroscopy (5 mm) along with an ultrasound examination was the main diagnostic modality. The laparoscopic procedure under general anesthesia included adhesiolysis if any, the lower uterine segment scar excision assisted by transvaginal illumination, and intra-corporeal re-suturing of uterine defect using a number zero polyglycolic acid suture in 2 layers. The post-menstrual bleeding abated in all 17 patients; 6/17 desired a 2nd pregnancy and they are under observation.

Hydrosonographic Assessment of the Effect of Two Different Suture Materials on Healing of the Uterine Scar after Cesarean Delivery: A Prospective Randomized Controlled Trial.

This study aimed to compare the effects of two different suture materials, monofilament synthetic absorbable sutures versus multifilament synthetic absorbable sutures, on healing the uterine scar after a cesarean delivery. A total of 95 women between the ages of 18 and 40 who had undergone a primary cesarean section (CS) after the 38th week of gestation. In Group I (n=48), continuous double-layer unlocked closure of the low transverse uterine incision was performed using monofilament synthetic absorbable sutures. In Group II (n=47), continuous double-layer unlocked closure of the low transverse uterine incision was performed using multifilament synthetic absorbable sutures. Six months after the operation, the integrity of the cesarean scar at the uterine incision site was assessed using hydrosonography. The healing ratio and the thickness of the residual myometrium covering the defect were calculated as markers of uterine scar healing. No statistically significant differences were observed between the groups with regard to the preoperative hemoglobin concentrations, the change in the hemoglobin concentrations, operating time, and the number of intraoperative additional hemostatic uterine sutures. Mean thickness of the residual myometrium covering the defect was thicker in the monofilament suture group in comparison to the multifilament suture group (7.76±2.11 vs. 5.96±1.69, respectively; p<0.01). The mean healing ratio was significantly higher in the monofilament suture group in comparison to the multifilament suture group (0.76±0.13 vs. 0.60±0.12, respectively; p<0.01) CONCLUSION: Continuous double-layer unlocked closure of the uterine incision at cesarean delivery using monofilament synthetic absorbable sutures decreases the risk of CS scar defect.

2144 Robotic Isthmocele Repair of a Big Cesarean Scar Defect - A Feasible Technique

Video Objective Describe a robotic isthmocele repair of a big cesarean section scar defect. Setting Isthmocele is a reservoir, pouchlike defect, at the site of a previous cesarean section, normally resulted of a cesarean scar defect or dehiscence. Its prevalence may be underestimated. A rare, but important repercussion, is cervical scar pregnancy, one of the rarest forms of ectopic pregnancy, with a high risk of uterine rupture and haemorrhage. Half of the cases occurs to patients who had only one prior caesarea. Isthmocele's treatment must be chosen among different alternatives (hysteroscopic, vaginal, laparotomic, laporoscopic), considering symptoms, plans for future conception, and the size of the defect. Isthmocele resection with myometrium myoplastia must be considered if the residual myometrium thickness is less than 3 mm. Interventions A 38-year old woman, with 1 previous cesarean section and 1 cervical scar ectopic pregnancy treated with methotrexate 8 months ago, preparing to concieve, presented with a large isthmocele. Preoperative MRI exhibited a 26 × 22 mm defect, with a 1 mm remaining myometrium. A robotic approach was used to identify the cervical niche, using a uterine manipulator with its tip balloon placed downwards, right above the internal cervical orifice. After correct identification, the bladder was caudally dissected and the uterine isthmus limits were completed exposed. The isthmocele was resected. All connective tissue was enucleated until vivid myometrium was seem all over its circumference. The defect was closed in two layers with 2.0 vicryl interrupted sutures. Conclusion Robotic isthmocele repair is a feasible technique when correctly chosen. Due to the raising number of cesarean sections, gynecologists will face this problem more frequently and must be aware of its indications as well as different approaches.

Agreement between transvaginal ultrasound and saline contrast sonohysterography in evaluation of cesarean scar defect

Objectivesto assess the agreement between saline contrast sonohysterography (SCSH) and transvaginal sonography (TVS) in the evaluation of cesarean section scar defect (CSD) regarding its width, depth, and shape and also in assessing the anterior myometrium, and residual myometrium related to the scar. Material and methodsa prospective study during the period between August 2017 and January 2018 was conducted in which 102 consecutive participants underwent primary cesarean section in Ain Shams University Maternity Hospital were assessed six weeks after CS to evaluate for CSD presence by using both SCSH and TVS. ResultsCSD could be detected only in 59.8% of women by TVS and 70.5% by SCSH with good agreement strength (Cohen kappa = 0.805). TVS was 84.72% sensitive and 100.00% specific in identifying CSD diagnosed by SCSH. The PPV, NPV, and accuracy of TVS were 100.00%, 73.17%, and 89.21%, respectively.The mean anterior myometrial thickness (AMT) did not differ when assessed by both TVS and SCSH, while the mean niche width was 2.56 ± 1.98 mm with SCSH compared to 2.17 ± 1.63 mm with TVS(r = 0.954), and its mean depth was 2.76 ± 2.02 mm for SCSH and 1.57 ± 1.51 mm in TVS(r = 0.812). The mean residual myometrium was 10.09 ± 2.74 mm in SCSH while was 11.18 ± 2.50 mm for TVS(r = 0.914) Conclusioncesarean scar defects in non-pregnant women are better evaluated at SCSH than at unenhanced TVS as more defects detected by SCSH and better evaluation of its shape, borders and size.

Laparoscopic Resection of Post–Cesarean Section Scar Uterine Cyst

Study ObjectiveTo demonstrate a technique of performing laparoscopic resection of a post–cesarean section scar uterine cyst. DesignTechnical video (Canadian Task Force classification III). SettingUniversity Hospital. PatientA 38-year old woman. InterventionLaparoscopic excision of a uterine cyst within a cesarean section scar. Measurements and Main ResultsA 38-year-old woman presented with secondary subfertility requesting removal of a cesarean section scar defect to prepare the uterine cavity for in vitro fertilization. Preoperative ultrasound demonstrated a 17.7 × 12.2 mm scar defect. At rigid hysteroscopy the anterior uterine wall cyst was observed and noted to be narrowing the uterine cavity. A laparoscopic approach was used to excise the uterine cyst. We carefully mobilized the bladder from its adhesions at the site of the previous cesarean section scar. The uterine cyst was located and margins of the defect identified. An ultrasonic-energy device was used to enucleate and excise the cyst. A uterine manipulator helped to identify the cervical canal and protect the posterior wall from inadvertent suture placement. The defect was closed with 1 vicryl interrupted sutures, being careful to incorporate the full thickness of the uterine wall to an able maximal opposition. An adhesion barrier was applied to the area. Transvaginal ultrasound scanning performed 6 weeks postoperatively demonstrated full healing with no residual defect. ConclusionNiches are recognized complications of cesarean sections resulting from incomplete healing of the scar and more likely in single-layer closures [1]. They can be associated with postmenstrual spotting, dysmenorrhea, chronic pain, subfertility, and poorer reproductive and obstetric outcomes [1–5]. Laparoscopic resection of niches is well established, showing symptomatic relief and an increase in residual myometrium [6]. Although cesarean section scar defects have been described as niches, we presented a further variety of defect that has not been previously described, a uterine cyst.

The minimally invasive approach to the symptomatic isthmocele - what does the literature say? A step-by-step primer on laparoscopic isthmocele - excision and repair.

The purpose of this review is to understand the minimally invasive approach to the excision and repair of an isthmocele. Previous small trials and case reports have shown that the minimally invasive approach by hysteroscopy and/or laparoscopy can cure symptoms of a uterine isthmocele, including abnormal bleeding, pelvic pain and secondary infertility. A recent larger prospective study has been published that evaluates outcomes of minimally invasive isthmocele repair. Smaller studies and individual case reports echo the positive results of this larger trial. The cesarean section scar defect, also known as an isthmocele, has become an important diagnosis for women who present with abnormal uterine bleeding, pelvic pain and secondary infertility. It is important for providers to be aware of the effective surgical treatment options for the symptomatic isthmocele. A minimally invasive approach, whether it be laparoscopic or hysteroscopic, has proven to be a safe and effective option in reducing symptoms and improving fertility. VIDEO ABSTRACT: http://links.lww.com/COOG/A37.

Sonographic evaluation of surgical repair of uterine cesarean scar defects.

The aim of the study was to assess the clinical outcomes of surgical repair of uterine cesarean scar defects with sonography (US). Seven nonpregnant women with history of cesarean section and a large uterine scar defect were enrolled. The surgical repair was performed by minilaparotomy. The US assessment of the uterine scar was performed using a standardized approach at baseline, then at a first visit 2-3 days following the surgical intervention (V1) and at a follow-up visit 3 months later (V2). Residual myometrial thickness (RMT), width, and depth of the scar defect were measured. The mean RMT increased significantly from 1.9 mm at baseline to 8.8 mm at V1 and 8.0 mm at V2. No intraoperative complications were observed. Postmenstrual spotting and abdominal pain reported preoperatively resolved after the operation. A surgical repair procedure for an incompletely healed uterine cesarean scar is effective in increasing RMT thickness, decreasing the depth of the scar, and reducing symptoms related to the cesarean section scar defect. Further studies on post-repair pregnancy outcomes are required to evaluate whether the procedure affects the rate of cesarean scar pregnancy, morbidly adherent placenta, and/or uterine scar dehiscence and rupture. The repair of a cesarean scar defect is recommended only for symptomatic women. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:455-460, 2017.

Can the final sonographic assessment of the cesarean section scar be predicted 6 weeks after the operation?

ObjectiveThe aim of the study was to compare the sonographic characteristics of the cesarean section (CS) scar 6 weeks and 6 months after operation. We tested the hypothesis that the dehiscence risk coefficient (DRC) measured 6 weeks and 6 month after CS does not change. Materials and MethodsA prospective longitudinal study was conducted in 43 primiparous women delivered by CS. The thickness of the myometrium proximal and distal to the CS scar, and the thickness of the CS scar were measured transvaginally. The severity of the CS scar defect was evaluated using the DRC. ResultsThe cut-off value (5th percentile) for the CS scar thickness and for DRC was 3.0 mm and 0.25, respectively. Statistical analysis revealed a significant correlation between DRC 6 weeks and 6 months after CS (correlation coefficient r = 0.97). ConclusionDRC can describe the defect of the CS scar adequately by the end of the puerperium.

Robotic-Assisted Laparoscopic Treatment of Residual Ectopic Pregnancy in a Previous Cesarean Section Scar: A Case Report

Study ObjectiveTo describe a technique of robotic-assisted laparoscopy of residual cesarean scar pregnancy (CSP) and uterine defect repair. DesignVideo case report, with step-by-step explanation of the procedure (Canadian Task Force classification III) SettingCSP may be treated by different approaches including surgery and methotrexate. Successful methotrexate treatments avoid an emergency surgical treatment. In these cases a residual CSP often remains and should be removed in women who desire to conceive. CSP is often associated with a cesarean section scar defect called an isthmocele. In case of isthmocele with important defect and desire for pregnancy, laparoscopic repair may be proposed. Diagnosis and treatment of isthmocele is usually performed in a second time after a successful treatment of CSP. In this case, a surgical treatment including the removal of the residual CSP and treatment of the isthmocele may be proposed. InterventionIn this video we describe a technique for the surgical removal of residual CSP and isthmocele treatment by robotic-assisted laparoscopy. A 32-year-old patient developed a CSP treated by 2 in situ injections of methotrexate. A magnetic resonance imaging study performed 1 month after the last methotrexate injection revealed a persistent 4-cm residual CSP, associated with an isthmocele. Preoperative uterine artery embolization was performed to reduce intraoperative bleeding. After localization of the residual CSP on the left side, a temporary left uterine occlusion was performed. Residual CSP was totally removed. The residual defect and isthmocele were closed using delayed absorbable suture. ConclusionRobotic-assisted laparoscopic removal of residual CSP and isthmocele treatment is a feasible and safe procedure. This procedure may be proposed in patients presenting with this condition after a methotrexate treatment of CSP.

Cesarean Section Scar Defect: Emerging Cause of Menstrual Irregularities—Case Series and Review of Literature

ABSTRACTCesarean section (CS) is the most common surgery in women of reproductive age group. We report three cases of cesarean section scar defect who presented to us with severe dysmenorrhea, menorrhagia, and postmenstrual bleeding. Diagnosis was made at transvaginalsonography (TVS). Laparotomy and repair of this defect resulted in relief of symptoms. Scar defect is a rare late complication of cesarean section leading to menstrual irregularity. Transvaginalsonography helps in detection and also defines the thickness and length of defect. Conservative surgical correction of the defect followed by menstrual suppression helps in relief of symptoms and can be considered as the first line in management.How to cite this articlePai AH, Kodandapani S. Cesarean Section Scar Defect: Emerging Cause of Menstrual Irregularities—Case Series and Review of Literature. Int J Infertil Fetal Med 2016;7(1):27-31.

Complete separation of the uterine cesarean section scar – a new cause of secondary infertility?

OBJECTIVE: To assess the risk factors and clinical symptoms related to the complete separation of the cesarean section (CS) scar in the nonpregnant uterus. DESIGN: Observational study. MATERIALS AND METHODS: The study group included twenty-five women with a history of low transverse CS in whom a complete separation of the CS scar was diagnosed using saline infusion sonohysterography (SIS) and hysteroscopy (HSC). The diagnosis of complete separation of the CS scar was made when at the site of the scar no myometrial tissue could be visualized. RESULTS: Fifteen women (60%) had a history of one CS, six (24%) had a history of two CSs and four women (16%) of three CSs. No statistically important difference was found between the number of previous CSs and complete separation of the CS scar (p>0.05). The type of the last CS before the diagnosis of the scar separation was as follows: in 8 cases (32%) elective CS, in 17 cases (68%) emergency intrapartal CS (p<0.05). None of the women had a history of puerperal infection. The mean interval between CS and diagnosis of scar separation was 14.6 months ( 10.6). Twenty-two women (88%) complained of spotting or bleeding after menstruation. The mean duration of spotting/bleeding was 6 days ( 2.9). Sixteen women (64%) desired future pregnancies. Among that group at the time of evaluation 10 women (62.5%) met the criteria of secondary infertility i.e. 12 months of contraceptive-free intercourse. None of the women was previously treated due to primary infertility. The male factor and ovulation disorders were excluded. One possible explanation of infertility in those patients might be the fact that in all cases during SIS and HSC procedures a blood clot protruding into the cervical canal was observed at the site of the CS scar defect. This may be considered as a mechanical factor causing infertility. During the follow-up one woman became spontaneously pregnant. In that case a CS scar pregnancy was diagnosed. This patient was successful treated with local methotrexate injections. CONCLUSION: Emergency CS may be considered as a risk factor for complete separation of the uterine CS scar. Women with secondary infertility and abnormal uterine bleeding that have a history of CS need to undergo ultrasonographic assessment of the CS scar. Further studies are needed to confirm if the complete separation of the CS scar is a risk factor for scar pregnancy. Also adequate treatment options for symptoms related to the complete separation of the CS scar should be developed.

Challenges in the transvaginal management of abnormal uterine bleeding secondary to cesarean section scar defect

ObjectiveResearch suggests that the resectoscopic management of abnormal uterine bleeding (AUB) following cesarean section (CS) is safe and effective. There is, however, a lack of complementary data from routine clinical practice. We aimed to evaluate the efficacy of resectoscopic remodeling of the CS scar in the management of post CS AUB (pCSAUB). Study designThe case notes of 57 women with pCSAUB who had undergone a resectoscopic remodeling procedure were reviewed retrospectively. Primary outcome measures were the duration of preoperative and postoperative menstruation, and postoperative menstrual change. Secondary outcome measures were the impact of patient-dependent variables on the success of the resectoscopic remodeling procedure. The CS scar was located using transvaginal ultrasonography and hysteroscopy. The remodeling procedure was performed with a hysteroscopic resectoscope, and commenced with resection of the fibromuscular scar. This started at the roof of the scar pouch and progressed towards the external os. It then continued along a line parallel to the axis of the cervical canal. The exposed dilated blood vessels and endometrial-like tissue in the roof of the remaining pouch were electrocauterized with a roller-ball electrode. ResultsThe mean operating time was 30.2±6.6min. There was a significant difference in the mean duration of preoperative and postoperative menstruation (12.9±2.9 days and 9.4±4.1 days, respectively; p<0.001). However, only 59.6% of patients (34/57) reported a postoperative improvement in symptoms. A significant postoperative improvement was observed more frequently in patients with anteflexed uteri than in patients with retroflexed uteri, and this difference was significant (90.6% (29/32) and 20.0% (5/25), respectively; p<0.001). No correlations were found between treatment outcome and age, body weight, parity, number of cesarean deliveries, duration of preoperative menstruation, or operating time. ConclusionsResectoscopic uterine remodeling is an appropriate therapy in patients with pCSAUB and an anteflexed uterus.

Pour le transfert embryonnaire sous échoguidage

to assess the agreement between saline contrast sonohysterography (SCSH) and transvaginal sonography (TVS) in the evaluation of cesarean section scar defect (CSD) regarding its width, depth, and shape and also in assessing the anterior myometrium, and residual myometrium related to the scar.a prospective study during the period between August 2017 and January 2018 was conducted in which 102 consecutive participants underwent primary cesarean section in Ain Shams University Maternity Hospital were assessed six weeks after CS to evaluate for CSD presence by using both SCSH and TVS.CSD could be detected only in 59.8% of women by TVS and 70.5% by SCSH with good agreement strength (Cohen kappa = 0.805). TVS was 84.72% sensitive and 100.00% specific in identifying CSD diagnosed by SCSH. The PPV, NPV, and accuracy of TVS were 100.00%, 73.17%, and 89.21%, respectively.The mean anterior myometrial thickness (AMT) did not differ when assessed by both TVS and SCSH, while the mean niche width was 2.56 ± 1.98 mm with SCSH compared to 2.17 ± 1.63 mm with TVS(r = 0.954), and its mean depth was 2.76 ± 2.02 mm for SCSH and 1.57 ± 1.51 mm in TVS(r = 0.812). The mean residual myometrium was 10.09 ± 2.74 mm in SCSH while was 11.18 ± 2.50 mm for TVS(r = 0.914)cesarean scar defects in non-pregnant women are better evaluated at SCSH than at unenhanced TVS as more defects detected by SCSH and better evaluation of its shape, borders and size.

Surgical treatment and follow-up of women with intermenstrual bleeding due to cesarean section scar defect

Previous cesarean delivery scar (PCDS) defect has been described as a cause of intermenstrual bleeding in women with no other uterine pathology except for a pouch on the anterior uterine segment at the site of the cesarean scar. The objective of this study was to assess the effectiveness of hysteroscopic surgery to correct this anatomic defect and eliminate the bleeding disturbance in a group of women with this symptom. Retrospective study (Canadian Task Force classification XX). Private hospital, department of obstetrics and gynecology. Twenty-four women, age 29-41 years, who reported intermenstrual bleeding, especially postmenstrual spotting, with no other gynecologic pathology except for the presence of a PCDS defect. Diagnosis was established with transvaginal ultrasound, when a fluid-filled, triangular defect was seen in the anterior uterine isthmus, in relation to the cesarean section scar. Hysteroscopic resection of fibrotic tissue that overhangs underneath the triangular pouch, facilitating blood drainage through the cervix and fulguration of endometrial glands and/or dilated blood vessels. The mean number of previous cesarean-section deliveries was 2.75. Postoperative follow-up was 24 months in 21 patients and at least 14 months in the other 3 patients. Eleven of these patients with the desire to become pregnant were unable to conceive after trying for a period of at least 2 years before hysteroscopy. Infertility work-up in the 11 patients revealed 9 with unknown infertility, 1 with male infertility, and 1 with failed tubal reversal surgery. Nine of them became pregnant between 14- and 24-months of follow-up. Eighty-four percent of patients (20/24) remained asymptomatic (without bleeding disturbances) after surgery. Previous cesarean delivery scar defect may be the cause of intermenstrual bleeding, and it is possible that it also may impair fertility, but it can be successfully treated by hysteroscopic surgery.